Adult Volunteer Application

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Thank you for your interest in the Adult Volunteer Program at Children's Mercy!

(Please note this application is for individuals 18 years and older and should not be completed for high school students.)

This application is used as a preliminary screening tool and does not guarantee placement. Please allow time to answer the questions fully as your answers will help guide us in the application process. Our main form of communication with you is through email, so please make sure that you provide an email address that you check often. Be sure to check your junk/spam email folder as messages sometimes go there.

If you are able to make a one year commitment to a weekly shift of approximately three hours, then please proceed with the the application.

If you are filling out this application on a mobile device, please make sure your screen orientation is unlocked and turn your phone to the side (landscape mode) to complete the application.

To Begin- create a user ID and password. You will use this user ID and password for additional steps in the onboarding process .

New User Details

User ID

User ID (verify)

Password

Password (verify)

Personal Demographics

* Legal First Name (as it appears on your social security card)

Legal Middle Name (as it appears on your social security card). If you do not have a legal middle name, enter n/a

* Legal Last Name (as it appears on your social security card)

Name suffix (you may also add any credentials you have, such as RN, MD, etc.)

Do you have a preferred first name that is different from your legal name? (Please leave this line blank if you do not)

Do you have a preferred middle name that is different from your legal name?

Do you have a preferred or shortened last name that is different from your legal last name?

* Date of Birth (Please enter as MM/DD/YYYY)

* Please enter your full 9 digit social security number without dashes (555555555). This is required to complete background screenings.

Gender

Do you speak any additional languages besides English? If so, please click the box in the scroll bar to drag the box up and down to select your language(s).  (The mouse scroll wheel tends to not scroll down):

Ethnicity New

Communication Methods

* Phone (Cell)

Would you like to be opted in to receive SMS/text messages?

Opt-in to SMS/text message

Opt-out of SMS/text message

Only one can be checked.

Phone (Work)

Phone (Home)

* Please enter a personal email address that you check often. All communication will be sent to the address you provide. If you are a CM employee you may not enter an @cmh.edu email address.

Do you have a secondary email address that you would like for us to have on file to cc all email communication to?

Primary Home Address

* Street address and any apartment/unit number

Line 2

* City

State

* Zip Code: Please enter this as your zip code + 4 digits. You can find this on most of the mail you recieve. (Example: 64108-2420)

Emergency Contact Information If you are an adult volunteer, but you require a parent/guardian to sign consents- please make sure to enter that person below.

* Emergency Contact First Name

* Emergency Contact Last Name

* What is your emergency contact's relationship to you?

* Emergency Contact E-mail Address:

* Emergency Contact Phone (Cell)

Emergency contact phone (home)

Emergency Contact Phone (Work)

Education

Are you currently enrolled in school?

Name of School

Employer

Are you currently employed?

* If yes, who is your employer?

Children's Mercy Affiliation(s)

Are you affiliated with Children's Mercy in any of the following ways? Please mark all that apply

I am not affiliated with Children's Mercy

I am a CM vendor

I am a CM donor

I am a current or previous CM volunteer

I have attended a CM event (such as Big Slick or Red Hot Night)

I am a current or previous CM patient

I know someone who is/was a CM patient

I have participated in a community fundraiser for CM

I have a connection to CM that is not listed

I am a current or previous CM employee

Please provide your current or previous Children's Mercy employee ID number if known

* CMH position title

* CMH department

* CMH location/site

Volunteer Affiliation(s)

Do you volunteer at any other organizations?

If yes, what other volunteer organizations do you serve?

Intake Assessment Questions

* Tell us about yourself and why you are interested in volunteering at Children's Mercy:

* Please share your availability; preferred days of the week and time of day:

* We seek volunteers who are kind and inclusive. Please describe a specific example of when you have worked in or served in a setting with individuals that came from different backgrounds and circumstances. How did you bring value and appreciation for these differences?

* To volunteer directly with patients in either our inpatient or outpatient settings, we ask that you have previous experience with children. These volunteer positions may include roles such as interacting with patients, siblings, and family members on inpatient units, or in exam or waiting rooms. It might also include supporting patients through craft activities, play, or reading to patients and young family members one on one or in a group setting. Please share your experience working with children:

* Some of our volunteer roles do not involve direct interaction with patients, but instead support staff or other program needs. These positions may include office support, wayfinding in the hospital, serving in our gift shop, or supporting families in the Kreamer Family Resource Center. Are you willing to serve in an office support or guest service role?

* Our current volunteer efforts are focused on filling our most critical roles within Children's Mercy and primarily at our downtown Adele Hall Campus. Are you willing to serve in any capacity or is there a specific role you are most interested in?

Do you have a specific Children's Mercy location where you are hoping to serve?

* We strive to create a supportive and inclusive environment for anyone in our community who wishes to serve patients and families at Children's Mercy. Do you require assistive/adaptive devices or equipment while volunteering?

Do you have any special skills that can contribute to a volunteer role?

Is there anything else you would like us to know about you? 

Consent and Acknowledgement Section
For adult volunteers (18+), please review, acknowledge each item below and sign this consent page.
For minor volunteers and adult volunteers with a guardian; your parent/legal guardian is required to review, acknowledge and sign their consent in order to participate in the volunteer program. This will be sent to them seperately via the email address listed in the emergency contact section of this application.

Are you legally able to sign your own consents?

* I understand that I am applying for a volunteer position to willingly donate my time to specific tasks for public service and that the duration of the volunteer role is temporary without receipt of compensation (this is an unpaid role). I understand that this application does not guarantee volunteer placement at Children's Mercy.

* I understand that this volunteer program requires a weekly commitment of a three hour shift for at least 12 consecutive months.

* I understand that I will be receiving e-mail communication regarding critical volunteer updates such as orientation, required trainings, scheduling, weather, etc. Children's Mercy expects all volunteer to review the information provided and respond if requested.

* I understand that for the safety of our patients, families and staff; the Children's Mercy Immunization Policy requires that all volunteers have: immunity to Measles/Mumps/Rubella and Varicella proof of one Tdap vaccination (many adults may have received from their primary care provider)proof of a seasonal flu vaccination (during flu season) screening for Tuberculosis (TB) as a blood test I agree to produce any childhood or current immunization records I might have that verify proof of previous vaccination.

* I give consent to have blood drawn in the Children's Mercy outpatient lab to screen for TB and immunity to Measles/Mumps/Rubella and Varicella, if needed. I understand that based upon these test results, additional vaccinations and/or tests may be required and I agree to receive/obtain any vaccines or tests that are necessary prior to volunteering. I understand that I may contact the Occupational Health Clinic (816) 234-3179 if I have questions.

* I understand that I am responsible for self-monitoring for symptoms of illness before volunteering at any Children's Mercy location or facility. If I have had symptoms of illness (cough, sore throat, shortness of breath, chills, body aches, fever) in the past 24 hours,  I will not enter a Children's Mercy facility.

* I agree to complete all initial and ongoing trainings that are required for this volunteer role.

* I give permission for Children's Mercy to take photographs of me as a volunteer; for badges and/or media related publications. I understand the Volunteer Services Department staff will not contact me when photographs are chosen for use in brochures or publications.

* I understand my requirements may change at any time due to the ever changing nature of healthcare and safety protocols.

* I give permission for Children's Mercy to request a background check upon initial enrollment in the volunteer program, and on a recurring basis as part of standard hospital procedure.

* I agree for Children's Mercy to complete a Kansas Family Care Safety Registry Checks (FCSR) upon placement and prior to serving as a volunteer.

* I agree to receive emergency medical care as needed if I become ill or injured while volunteering at Children's Mercy.

* Typed Signature

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Signature

General Volunteer Questions
volunteer@cmh.edu
(816) 302-1020

Groups, Donations, & Junior Champions
donategoods@cmh.edu
(816) 302-1020

Parent Advisory Councils & POPS Mentors

pfa@cmh.edu

(816) 302-3800

Teen Advisory Councils

awoelk@cmh.edu

(816) 234-3702

Volunteering with a Disability

klgomer@cmh.edu

(816)-234-3000 ext. 51869

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